Critical Cases - Deadly Foot Pain?


  • 55 yo female with 2 day history of atraumatic R foot pain 
  • Pain is over the dorsal foot and worse with ambulation, also present at rest
  • There is associated parasthesias of the dorsal foot
  • She denies swelling, redness, warmth, fevers, or any recent wounds
  • She has no prior history of extremity surgeries or pathology


T 97.6  HR 88  BP 143/63  RR 18

  • Well appearing in no acute distress
  • Heart sounds normal no mrg
  • Lungs clear to auscultation
  • Abdomen soft, NTND
  • R lower exremity: There is purplish discoloration of the distal dorsal foot and all toes. The dorsal foot is cool to the touch. There is no palpable DP or PT pulse, and a weak Doppler DP signal

Differential Diagnosis - A focus on life&limb threats

  • Infection - necrotizing fasciitis, gangrene
  • Acute Limb Ischemia 
  • Compartment Syndrome
  • DVT


  • Vascular surgery consulted
  • Patient sent for CTA of lower extremity which demonstrated occlusion of R tibioperoneal trunk 

Management and Outcome

  • Pt treated with ASA and a heparin infusion in the ED
  • Taken immediately to OR for thrombectomy with successful restoration of perfusion
  • Pt recovered well with full function of the exremity

Take Home Points

  • Acute Limb Ischemia is a surgical emergency: there is a 20% amputation rate and 25% short term mortality rate
  • Pts often present with pain or pain and parasthesias only instead of the classic "6 Ps:" Pain, parasthesias, paralysis, poikilothermia, pallor, pulselessness"
  • Patients may have a palpable (though diminished) or Dopplerable pulse and still have acute limb ischemia
  • Sx more dramatic for embolic etiology without collateral circulation
  • In pts with longstanding disease, collateral circulation may prevent the more dramatic symptoms such as discoloration and severe, intractable pain
  • Outcomes completely dependent on time to intervention: beyond 4 hours there is irreversible necrosis of nerves and muscles resulting in poor outcomes such as amputation
  • Call vascular surgery early and initiate heparin therapy if there is a suspicion for acute limb ischemia: do not wait for diagnostic studies

Santistevan, Jamie. Acute Limb Ischemia - An Emergency Medicine Approach. Emerg Med Clin N Am 2017;35:889-909.